ED Coding and Reimbursement Alert

Even after a coder in a teaching hospital learns the basics of Medicare's guidelines for reporting resident services, she often needs guidance applying those rules when a resident from another specialty is involved. Simple Resident Visits Frequently, the standard guidelines for supervising physicians in teaching settings, as found in section 15016 of the Medicare Carriers Manual, apply without complication. Scenario: A patient is seen in the ED for a non-displaced fractured finger. Because this hospital participates in an approved graduate medical education (GME) program, it has a policy to bring in an orthopedic resident for all fracture cases. The ortho resident examines the patient and, under the direct supervision of the emergency physician, who would typically handle routine fractures, splints the finger.

Services rendered by residents in PATH (physicians at teaching hospitals) settings are decidedly circumscribed, even in straightforward circumstances. Documentation rules govern both E/M services and other procedures or services, with variations in each case. PATH Rules for E/M While the only services performed by the medical student that can be used in documenting E/M services are the past, family, social history (PFSH) and review of systems (ROS), residents may gather the entire H&P as long as there is clear documentation that the physician performed and documented the key portions of the history, physical exam and medical decision-making, says Jim Blakeman, senior VP with Healthcare Business Resources Inc. in Bala Cynwyd, Pa. Because residents often provide the entire service, with attending physicians repeating the key portions, coders should be on the lookout for markers to distinguish between the attending physician's and the resident's information. Many hospitals have separate sections in the chart to segment documentation so coders can distinguish between the residents' handwriting and that of their attending physicians. Problems multiple like flies "when coders can't tell who did what," Blakeman notes. He recommends returning unclear charts and requesting written clarification: "As long as what is included as an addendum to the medical record is reasonably contemporary, that's an adequate note to supplement the chart." PATH Rules for Procedures Other procedures a resident might perform are governed largely by the service's length and complexity. Medicare considers services of three to five minutes "minor" and requires the attending physician to be physically present and "elbow-to-elbow" to the resident. Major procedures requiring more than five minutes oblige the attending physician to document that he or she was present or performed the key portion(s) of the procedure. For example, a resident may perform all of the fracture care (e.g., 26740, Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each), but the attending must document his or her presence for the key portions of the procedure e.g., exploration of [...]